1997 WHRG Grant Program

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Symposia

National Trends in the Treatment of Depression in Women
Sheila Weiss, Ph.D.
School of Pharmacy, University of Maryland, Baltimore

The United States' health care delivery system is undergoing a rapid and dramatic shift from the traditional fee-for-service insurance system to a managed care, capitated approach. This shift poses serious questions about the extent of services provided, as well as their access and availability, particularly for patients with chronic conditions. Therefore, we propose to investigate the changes in the treatment of women with depression over a six year period. Depression is the area selected for this study because it is the most prevalent mental disorder and it affects women disproportionately more than men. Antidepressant (ATD) medication is the most common somatic treatment; care is delivered in outpatient settings primarily by primary care physicians. Several reasons to study treatments for depression can be cited. First, the substantially greater drug costs for the recently marketed, widely used antidepressant class of Selective Serotonin Reuptake Inhibitors (SSRIs) make them a target of interest for managed care cost containment programs. Secondly, the tendency to add medications (e.g., anxiolytic or hypnotic agents for treatment-emergent anxiety or insomnia) to the ATD drug regimen poses clinical questions because these combinations have not been studies for effectiveness and safety. Thirdly, the co-occurrence of psychotropic agents with exogenous hormones is of interest because of the potential for drug-drug interactions. These questions can be addressed, in part, by data analysis to tease apart the relationship of drug selection, provider specialty, and payment source. The preliminary findings, in themselves, should contribute to the national debate about the standard of health care services provided under managed care initiatives. Two data sources (NAMCS and NHAMCS) from the National Center of Health Statistics will be used to create a dataset to address the following aims:

to show the national 6-year trend for total prevalence of ATD use in office-based visits (NAMCS), among women with a diagnosis of depression from 1989 through 1994; to show the age-, race-, region-specific and co-morbidity prevalence for ATD office-based visits;
to compare the relationship between the type of health insurance, patient characteristics, provider characteristics, and geographic region for the most recent years (1993 and 1994) for treatment received during the office-based visits (NAMCS) as compared with treatment received at hospital-based outpatient departments (NHAMCS);
among women with ATD treatments, compare the extent of co-occurring anxiolytics and hypnotics for women receiving SSRI treatment with women receiving a first generation ATD (tricyclic antidepressants (TCAs), controlling for diagnosis and age;
show the co-occurrence of hormone therapy [oral birth control pills (obcs) and hormone replacement therapy(hrt)] with ATDs and anxiolytics.

This study will characterize women's use of medical care for the treatment of depression in the usual practice setting and the clinical decision-making related to medication use in that setting across the United States. Findings will be used to support an application to the National Institute of Mental Health (NIMH), Services Branch, for a prospective study of outcomes of drug therapy for depression in women treated in the primary (managed) care setting.